Effects of video interaction analysis training on nurse patient communication in the care of the elderly

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1 Ptient Eduction nd Counseling 39 (2000) locte/ pteducou Effects of video interction nlysis trining on nurse ptient communiction in the cre of the elderly, Wilm M.C.M. Cris-Verhllen MSc, RN *, Ad Kerkstr PhD,,b c Jozien M. Bensing PhD, Mieke H.F. Grypdonck PhD Deprtment of Nursing nd Cring Reserch, Netherlnds Institute of Primry Helth Cre, NIVEL, P.O. Box 1568, 3500 BN Utrecht, The Netherlnds b Deprtment of Clinicl nd Helth Psychology, University of Utrecht, Utrecht, The Netherlnds c Deprtment of Nursing Science, University of Utrecht, Utrecht, The Netherlnds Received 5 Jnury 1999; received in revised form 20 June 1999; ccepted 10 July 1999 Abstrct This pper describes n empiricl evlution of communiction skills trining for nurses in elderly cre. The trining progrmme ws bsed on Video Interction Anlysis nd imed to improve nurses communiction skills such tht they py ttention to ptients physicl, socil nd emotionl needs nd support self cre in elderly people. The effects of the trining course were mesured in n experimentl nd control group. They were rted by independent observers, by compring videotpes of nursing encounters before nd fter trining. Forty nurses prticipted in 316 videotped nursing encounters. Multi-level nlysis ws used to tke into ccount similrity mong sme nurse encounters. It ws found tht nurses who followed the trining progrmme, provided the ptients with more informtion bout nursing nd helth topics. They lso used more open-ended questions. In ddition, they were rted s more involved, wrmer nd less ptronizing. Due to limittions in the study design, it could not be demonstrted tht these findings cn entirely be scribed to the trining course. Further reserch, incorporting rndomized controlled design nd lrger smple sizes, is recommended to determine whether the results cn be ttributed to this specific type of trining Elsevier Science Irelnd Ltd. All rights reserved. Keywords: Nurse ptient interction; Communiction trining; Elderly cre; Observtion study 1. Introduction ptient interction is n importnt spect in nursing the elderly. Yet, vriety of studies suggest tht It is generlly greed tht the qulity of nurse nurses overlook ptients socil nd emotionl needs, focus on physicl cre insted nd interct *Corresponding uthor. Tel.: ; fx: with their ptients in superficil wy [1 5]. Aprt from tht, nurses seem to hve dopted inppro- E-mil ddress: w.cris@nivel.nl (W.M.C.M. Cris-Verhllen) prite communiction styles [6]. Severl studies into / 00/ $ see front mtter 2000 Elsevier Science Irelnd Ltd. All rights reserved. PII: S (99)

2 92 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) verbl communiction show tht nurses convers- 2. Communiction trining tion style is dependency creting, for instnce in its use of secondry bbytlk, which is defined s The generl ims of the trining progrmme were set of ccommodtions including simplifiction nd to improve nurses communiction skills such tht high nd vrible pitch, usully ddressed to chil- they py ttention to ptients physicl nd socil dren, but lso used in tlking to the elderly [7 9]. needs, fcilitte selfcre in elderly ptients nd Nurses lso tend to exercise power in their com- support them in finding their own solutions to their munictive style nd hve tendency to tret problems, in sted of giving the usul solutions from ptients in routine wy without bothering to the professionl vntge point [28]. explin wht they re doing. This my result in Trining focused on: uncertinty in ptients [10]. By explining their behviour nd intentions, i.e. by formulting gols Development of nurses wreness of the physnd sying wht they re doing, nurses my reduce icl, socil nd emotionl needs of the elderly. ptients feelings of uncertinty nd thereby in- Verbl communiction techniques, such s, struccrese the qulity of cre [11]. turing, exploring ptients ides nd opinions. In ddition to verbl behviour, vriety of Enhncing ptients feelings of competence, by studies hve underscored the importnce of dequte supporting them in finding their own nswers. nonverbl behviour. Nonverbl behviour is the This requires nurses to show verbl ttentiveness pre-eminent mode of building rpport with other (prphrsing nd encourging utternces like persons nd of conveying empthy nd support [12 uhm s nd h s ) nd help ptients to explore 16]. For instnce looking, smiling nd nodding t the topic by mens of open-ended questions someone conveys interest nd wrmth [17,18] nd (Wht did you think the solution ws? Wht hd such gestures pper to contribute positively to you tried before? etc.). others perceptions of competence nd credibility Nonverbl behviours, such s looking t the [11,17,19]. Besides, touch is lso very importnt ptient while listening, stimulting the ptients spect in estblishing reltionship nd cn convey tlk by hed nodding nd forwrd lening s ffection, cre nd comfort [20 22]. sign of ttention. In response to the problems mentioned bove, teching communiction skills is often promoted An importnt prt of the trining ws dedicted to during nd fter the voctionl trining of nurses. Video Interction Anlysis sessions in which pirs of However, simply giving nurses new protocols to trinees, guided by their triner, wtched nd disfollow is not enough to chnge ptterns of inter- cussed videotpes of their own performnce during ction. Eductionl progrmmes should py ttention nursing encounters. to both verbl nd nonverbl communiction in In its entirety, the communiction skills trining relistic situtions [23]. For this reson, the use of progrmme combined: video is often recommended in trining helth cre professionls. It is interesting to note tht video A 2-dy introductory course, with theoreticl feedbck is widely used in medicl nd GP trining introduction on communiction in nursing nd the [24] but thus fr it hs not been very common in geing dult, n explntion of the Video Intertrining nurses [25 27]. Recently, group of nurses ction Anlysis method nd communiction prcwere trined using Video Interction Anlysis. The tice during role-ply presenttions with nurse present study exmines the effects of this trining. ptient interctions. In the role-ply, ptients were The min reserch question to be ddressed is: simulted by ctors. Wht re the effects of communiction trining, Six smll group sessions in which two trinees, bsed on Video Interction Anlysis, on the com- guided by the triner, nlysed nd discussed their munictive behviour of nurses nd ptients in own videotped nursing encounters. During these elderly cre? sessions, three types of lerning processes were

3 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) supposed to tke plce: nturl lerning from the nurses in the control group did not remin in the trinee s own review of performnce on tpe, peer study until the lst mesurement. Resons were: comments nd triner feedbck. resigntion (n 5 3), illness/ pregnncy (n 5 3), Homework: the sessions lternted t 6-week chnge of job (n 5 1). The effects of the trining intervls in which trinees prctised the pplic- were determined on the bsis of dt from 40 nurses. tion of wht they hd lerned. They lso prepred Tble 1 summrizes nurses chrcteristics in both the next Video Interction Anlysis session by groups. There were no significnt differences berecording nursing encounter on video, which tween experimentl nd control group with respect to they hd to nlyse individully in dvnce. the bckground chrcteristics. At the end of the course, there ws plenry meeting with the trinees, who prticipted in the 3.2. Procedure introductory course. During the meeting, experiences were discussed nd the course ws Prior to nd 2 months fter completing the trinevluted with respect to its structure, process nd ing, videotped dt of nurse ptient interction ws personl results. collected. For tht purpose, ech prticipting nurse ws followed for prt of the dy, during which bout In terms of the ims of the trining, trinees were four nursing encounters were recorded. Nurses reexpected to py more ttention to both the physicl cruited the ptients for this study. A few dys prior nd socil needs of ptients, to be more supportive, to dt collection, nurses informed their ptients less dominnt, to disgree less nd show more bout the reserch, nd sked ptients to give empthy. Trinees were lso expected to demonstrte informed written consent to llow the recording for more rpport-building nonverbl behviour, such s reserch purposes. Very sick ptients, ptients sufferptient-directed eye gze, ffirmtive nodding, smil- ing from dementi nd terminlly ill ptients were ing, lening forwrd, nd touch [17,29]. Finlly, it excluded from prticiption. Very few home cre ws hypothesized tht ptients in the intervention ptients refused to prticipte. In the home for the group would tke more ctive prt in the inter- elderly, hlf of the sixty residents who were sked to ction. prticipte did so during the pre-test. During the post-test, prticiption incresed to 75%. Nurses did not systemticlly inform the reserchers bout those 3. Methods ptients who did not wish to cooperte, but they reported tht there ws no cler difference between 3.1. Design nd smple the prticipting nd non-prticipting residents. Moreover, the two groups of ptients could be Effects of the progrmme were mesured in considered representtive smples of the popultions pre-test post-test control group design. The ex- of ptients in the community nd in homes for the perimentl group included 24 nurses who hd prtici- elderly, with regrd to ge nd gender [29]. In totl pted in the trining nd the control group consisted 241 ptients prticipted. There were no significnt of 23 nurses who prticipted in the trining lter on. differences in ptient chrcteristics, between pre- The nurses were working in two different settings: in nd post-test (Tble 2). home cre orgnistion nd in home for the Before trining, the intervention group recorded elderly. All nurses who met the inclusion criteri, i.e. 87 nd the control group 69 encounters. After of hving completed bsic nursing trining nd trining, the figures were 87 nd 73, respectively. being involved in direct ptient cre ctivities, were Ech encounter ws videotped entirely using sked to cooperte. As ll subjects plnned to mnned cmer. The encounters hd men durtion prticipte in the trining, ssignment to experimen- of 18 min (rnge ). Of the pre-test smple, tl or control group ws mostly on prcticl criteri. 20% of the encounters were dominted by psycho- Two nurses in the experimentl group nd five socil cre nd the remining 80% of the visits,

4 94 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) Tble 1 Comprison between nurses in the experimentl nd control group with respect to bckground chrcteristics Bckground chrcteristics Prticipnts in the study Experimentl Control Test group group (n 5 21) (n 5 19) Gender Femle 95.2% 100% Mle 4.8% b Eductionl level Nurses 42.8% 31.6% 2 x Auxiliry nurses 57.1% 68.4% df 5 1 P Age in yers t df 5 37 P Yers of employment s t nurse (yers) df 5 37 Number of nurses working in () Home cre 52.4% 47.3% P x (b) Institutionl cre 47.6% 52.6% df 5 1 P To test the differences in bckground chrcteristics t-tests nd x tests were used. b Nurses 5 Dutch higher professionl eduction level, HBO or 3.5 yers of in-service eduction; Auxiliry nurses 5 Dutch secondry professionl eduction level, MBO or 2.5 yers of in-service eduction. Tble 2 Distribution of ge, sex nd durtion of receiving nursing cre of ptients who took prt in the study (n 5 241) Pre-test Post-test Totl Home cre Home for the elderly Totl Home cre Home for the elderly n (75%) 28 (25%) (64%) 47 (36%) Gender Femle 77 (71%) 54 (67%) 25 (89%) 100 (76%) 59 (69%) 41 (87%) Mle 32 (29%) 27 (33%) 3 (11%) 32 (24%) 26 (31%) 6 (13%) Men ge Men durtion of received nursing cre in months involved hygiene or technicl nursing cre. During the post-test, these percentges were 30 nd 70, respectively. The verbl communiction process ws nlysed using n dpted version of Roter s Interction Anlysis System (RIAS) [31], dpted by Cris- Verhllen et l. [32]. The system is widely used, hs 3.3. Assessment been shown to be relible [33 36] nd ws reltively fvourbly judged in comprtive study [37]. In Observtions nd nlysis of communiction ddition, RIAS is most suitble for our study, becuse it pys ttention to socio-emotionl nd tsk-relted communiction. The dpted version contins 24 verbl ctegories which were grouped into five clusters of more generl communiction behviours [38]. These in- clude: Nurse ptient communiction ws mesured by two independent observers, who were not informed bout the experimentl conditions. They used the CAMERA computer system [30], which is especilly designed for coding behviourl interction directly from video recordings.

5 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) Socil communiction, contining socil con- (men Person s r 0.91) [32,38], observtion time verstion tht hs no prticulr function in nurs- ws stndrdized to the first 10 min. Interrter ing ctivities, such s personl sttements, smll relibility for verbl nd nonverbl communiction tlk nd bnter. behviours ws sufficient, rnging between 0.70 nd 2. Affective communiction, contining verbl tten (Person s r) [29,38]. tiveness, concern nd empthy with the ptient. 3. Communiction tht structures the encounter, Assessing the effects of trining involving utternces tht indicte guidnce nd Before exmining specific trining effects, overll direction such s providing orienttion nd in- chnges in nurses communiction behviour were struction, mking requests for clrifiction, sking explored by nlysing the five generl verbl comfor understnding nd sking for opinions. muniction behviours. These revel informtion 4. Communiction bout nursing nd helth, con- bout the mount of ffective nd tsk-relted comtining ll items with respect to nursing, helth, muniction nd the converstion topics, i.e. on medicl or therpeutic topics. nursing nd helth or lifestyle nd emotions. 5. Communiction bout lifestyle nd feelings, con- In ddition, severl verbl composites were clcutining ll items with respect to lifestyle nd lted, relted to the hypotheses in the study. These emotions. included: the number of questions in generl, openended questions nd closed questions; mesure In ddition to verbl communiction, five nonverbl summing up ll utternces of giving informtion nd behviours were observed which were considered to mesure for the number of counselling utternces be essentil for building rpport [17]: ptient directed nd dvice, reflecting the supportive ttitude of the eyegze, ffirmtive nodding, smiling, lening for- nurse. Besides, the mount of disgree nd criticism wrd nd touch. Becuse touch is inherent in nursing were mesured. Both verbl cluster mesures nd ctivities, distinction ws mde between instrumen- composites re expressed s proportionl frequencies tl touch, which is necessry in performing tsk, relting to the totl number of utternces. A mesure nd ffective touch which expresses ffection. Only of nurses verbl dominnce ws clculted by the the ltter plys role in rpport building. men speking time in minutes. In ddition to these The nonverbl ctegories were expressed s pro- verbl mesures, the men proportion of nonverbl portions. The totl registered time in ptient directed ctegories nd ssessments on globl ffect rtings eyegze, forwrd lening, ffective touch nd were investigted. instrumentl touch ws divided by the durtion of The ptients ctive prt in the interction ws time tht nurse nd ptient were in sight. Similrly, ssessed with verbl composite scores, tht were the time spn of nodding nd smiling were comprble with those of the nurses. However, no divided by the time tht the nurse s fce ws in sight. distinction ws mde in type of questions. Further- In ddition to the observtion of specific nonverbl more, the ctegory of counselling nd dvice hd behviours, the generl ffective impression of slightly different definition nd referred to utternces nurses communiction ws rted on seven 6-point in which ptients formulted solutions to their own rting scles, mesuring irrittion, nervousness, s- problems. sertiveness, interest, wrmth, ptronizing nd involvement (1 low, 6 high) [31,32] Sttisticl nlysis Following Henbest nd Fehrsen [39], who noted tht scoring only prt of consulttion ws s The dt set in this study consists of two levels. relible s scoring n entire consulttion, preliminry The level of the encounter nd the level of the nurse. ssessments with observtion periods of 5 min, 10 The observtions t the encounter level were exmin nd the totl length of the encounter were pected to be explined by interventions t the nurse crried out on 48 encounters nd compred. As level [40]. A complicting fctor in nswering the 10-min observtion periods proved to be very reli- reserch question ws tht the 316 encounters cnnot ble when compred with the totl observtion time be considered completely s independent observ-

6 96 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) tions. As ech individul nurse hs her own be- ences in the experimentl group were tested ginst hviourl style, it might be rgued tht the encoun- men pre-test post-test differences in the control ters of one nurse, on verge, would resemble one group by mens of interction-tests. The nlyses nother more thn those of different nurses [12]. In were performed with MLn softwre [41]. n erlier study, [29] we clculted intr-clss correltion coefficients to determine this interdependency. These coefficients reflect the proportion of totl 4. Results vrince of n observtion ssocited with the clss (the nurse) to which it belongs. The mgnitudes of 4.1. Nurses verbl communiction intrclss correltions necessitted the use of multilevel nlysis. This type of nlysis cretes the The men proportions of verbl behviour, clcuoption of nlysing dt t the encounter level, lted for the two different settings seprtely, re without disregrding the interdependency t the level displyed in Tbles 3 nd 4. Contrst nlyses were of the nurses. Dt were, therefore, nlysed in mde between the scores of the trined nurses t the hierrchicl liner models, which were lso con- post-test nd the other mesurements. In both settrolled for type of nursing ctivity, s the ltter hd tings, we see minor ltertions in the five communibeen shown previously [38] to be relted to nurse ction behviours (upper prt of Tbles 3 nd 4), communiction. Contrst nlyses were crried out indicting tht the generl communiction ptterns to test for differences between the pre- nd post- did not chnge with different mesurements. As mesurements within the control nd the experimen- regrds the verbl composites, it ppers tht tl groups. In ddition, men pre-test post-test differ- chnges in the experimentl group were most strong- Tble 3 Weighted men proportions nd stndrd errors of nurses verbl communiction nd composites of nurses verbl communiction behviours t pre- nd post mesurement, in the home cre orgnistion Vribles Experimentl group Control group P Pre Post Pre Post n 5 44 n 5 43 n 5 31 n 5 35 encounters encounters encounters encounters M (S.E.) M (S.E.) M (S.E.) M (S.E.) Verbl communiction clusters Socil communiction (0.037) (0.038) (0.046) (0.042) 0.50 Affective communiction (0.025) (0.026) (0.031) (0.028) 0.60 Communiction tht structures the encounter (0.019) (0.019) (0.023) (0.021) 0.50 Communiction nursing nd helth cre (0.030) (0.031)* (0.038) (0.034) 0.50 Communiction lifestyle nd feelings (0.019) (0.020) (0.024) (0.022) 0.75 Verbl composites Disgreement (0.002) (0.002)** (0.002) (0.002) 0.30 Questions (0.014) (0.014) (0.017) (0.015) 0.30 Closed questions (0.012) (0.012) (0.015) (0.014) 0.35 Open-ended questions (0.003) (0.004) (0.004) (0.004) 0.40 Informtion (0.023) (0.023)** (0.028) (0.026) 0.50 Counselling nd dvice (0.004) (0.004)** (0.005) (0.005) 0.30 Speking time (min) 2.64 (0.161) 2.56 (0.165) 1.98 (0.196) (0.181) 0.45 Significnce level bsed on interction tests of men pre-test post-test differences in experimentl nd control group. Pre-test versus post-test: * P # 0.05; ** P # 0.01.

7 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) Tble 4 Weighted men proportions nd stndrd errors of nurses verbl communiction nd composites of nurses verbl communiction behviours t pre- nd post mesurement, in the home for the elderly Vribles Experimentl group Control group P Pre Post Pre Post n 5 43 n 5 44 n 5 38 n 5 38 encounters encounters encounters encounters M (S.E.) M (S.E.) M (S.E.) M (S.E.) Verbl communiction clusters Socil communiction (0.054) (0.048) (0.057) (0.053) 0.90 Affective communiction (0.029) (0.026) (0.031) (0.029) 0.80 Communiction tht structures the encounter (0.017) (0.015)* (0.018) (0.017) 0.25 Communiction nursing nd helth cre (0.023) (0.020) (0.024) (0.023) 0.75 Communiction lifestyle nd feelings (0.019) (0.017) (0.020) (0.019) 0.75 Verbl composites Disgreement (0.002) (0.001) (0.002) (0.001) 0.90 Questions (0.011) (0.010) (0.012) (0.011) 0.90 Closed questions (0.010) (0.009) (0.011) (0.010) 0.90 Open-ended questions (0.003) (0.003) (0.003) (0.003) 0.75 informtion (0.020) (0.018) (0.021) (0.020) 0.85 Counselling nd dvice (0.003) (0.003)** (0.003) (0.003) 0.30 Speking time (min) 2.05 (0.176) 2.19 (0.165) 1.82 (0.191) 2.09 (0.185) 0.10 Significnce level bsed on interction tests of men pre-test post-test differences in experimentl nd control group. Pre-test versus post-test: * P # 0.05; ** P # ly evidenced in home cre. Severl significnt con- elderly, no other differences were found between the trsts emerged. At the post-test, trined nurses scores of the control nd the experimentl group t ppered to give significntly more informtion, in the pre- nd post-test. prticulr, informtion bout topics on nursing nd In some instnces Tbles 3 nd 4 show improvehelth cre. They showed signs of disgreement, ments of verbl communiction of the untrined misunderstnding or criticism less often nd gve nurses, lthough the pre- nd post-test differences do less dvice. When looking t the type of questions, it not rech sttisticl significnce. Using open-ended ppered tht closed questions were used more questions, for instnce, improved from (prefrequently thn open questions, which encourge test) to (post-test) in untrined nurses in home ptients to tell their story. In the experimentl group, cre orgniztions (see Tble 3). To ccount for the the number of open-ended questions hd significntly vrious improvements in the untrined group, no incresed, while the totl number of questions re- mtter how smll they re, we hve tested the mined more or less the sme. equlity of the pre- nd post-test differences in the In the home for the elderly (Tble 4) we see t trined nurses ginst the pre- nd post-test differpost-mesurement tht experimentl nurses mde ences in the untrined nurses. The P-vlues of these fewer utternces providing guidnce nd direction (interction) tests re shown in the right-most colsuch s giving orienttion nd instruction, mking umn of Tbles 3 nd 4. None of the test sttistics requests for clrifiction nd sking for understnd- reched sttisticl significnce. This mens, for ing, compred with the pre-test. As in home cre, the exmple, tht lthough the trined nurses in home mount of counselling nd dvice hd decresed in cre orgniztions improved in using open-ended nurses in the experimentl group. In the home for the questions (pre-test) to (post-test), their

8 98 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) performnce improved not significntly more thn nurses showed more interest in their ptients, were tht of the untrined nurses. The sme goes for ll wrmer nd more involved, nd they behved in the verbl communiction clusters nd composites of less ptronizing wy. Contrry to expecttions, the Tbles 3 nd 4. So, the positive chnges we found in control group shows lso n increse in interest. the experimentl group cnnot be ttributed com- Moreover this group shows nother unexpected pletely to the intervention. effect. The degree of nervousness is significntly lower t the post-test compred to the pre-test. This 4.2. Nurses nonverbl communiction is possibly due to high bseline score for nervousness t the pre-test, which ws significntly higher, In home cre, contrry to expecttion, we see when compred with the other group. In the home decrese in two nonverbl behviours in the ex- for the elderly we see severl significnt chnges in perimentl group (Tble 5). Experimentl nurses globl ffect rtings. Nurses in the experimentl smiled to lesser extent nd lened forwrd less group were rted s more interested, involved nd frequently, fter the trining. These differences were wrm during the post-test. In ddition, they were less not pprent in the control group. In the home for the ptronizing. These chnges were not found in the elderly (Tble 6) no effects with respect to the five control group. nonverbl behviours were found within the two The right column of both Tbles 5 nd 6 shows groups. the P-vlues of the (interction) tests on the equlity In both settings, the experimentl groups showed of the pre- nd post-test differences of the trined more chnges in the globl ffect rtings thn in nurses ginst the pre- nd post-test differences of specific nonverbl behviours. In home cre we see the untrined nurses. The results show tht none of four significnt differences in the experimentl the tests rech sttisticl significnce t Lookgroup, ll in the direction expected. After trining, ing t the P-vlues between 0.05 nd 0.10 for trends, Tble 5 Weighted men proportions nd stndrd errors for nonverbl communiction t pre- nd post mesurement, in the home cre orgnistion Vribles Experimentl group Control group P Pre Post Pre Post n 5 44 n 5 43 n 5 31 n 5 35 encounters encounters encounters encounters M (S.E.) M (S.E.) M (S.E.) M (S.E.) Nonverbl behviour Eye gze (0.042) (0.043) (0.053) (0.046) 0.30 Affirmtive hed nodding (0.005) (0.005) (0.006) (0.006) 0.30 Smiling (0.003) (0.003)* (0.004) (0.003) 0.30 Forwrd lening (0.006) (0.005)* (0.008) (0.007) 0.40 Affective touch (0.003) (0.003) (0.003) (0.003) 0.70 Globl ffect rtings Anger/ irrittion 1.04 (0.074) 1.05 (0.075) 1.00 (0.093) 1.12 (0.082) 0.20 Nervousness 1.07 (0.144) 0.99 (0.148) 1.34 (0.178) 0.97 (0.162)* 0.15 Dominnce 2.92 (0.189) 2.68 (0.194) 2.93 (0.234) 2.85 (0.213) 0.50 interest 4.34 (0.186) 4.66 (0.190)** 4.09 (0.221) 4.58 (0.208)* 0.40 Wrmth 3.90 (0.222) 4.64 (0.227)*** 3.79 (0.266) 4.14 (0.249) 0.10 Ptronizing 1.93 (0.157) 1.31 (0.162)*** 1.39 (0.194) 1.09 (0.178) 0.15 Involved ttitude 3.78 (0.173) 4.23 (0.178)** 3.54 (0.214) 3.90 (0.196)* 0.70 Men durtion encounter 27.1 (2.6) 23.9 (2.6) 22.8 (3.2) 24.7 (2.8) 0.20 (min) Significnce level bsed on interction tests of men pre-test post-test differences in experimentl nd control group. Pre-test versus post-test: * P # 0.05; ** P # 0.01; *** P #

9 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) Tble 6 Weighted men proportions nd stndrd errors for nonverbl communiction t pre- nd post mesurement, in the home for the elderly Vribles Experimentl group Control group P Pre Post Pre Post n 5 43 n 5 44 n 5 38 n 5 38 encounters encounters encounters encounters M (S.E.) M (S.E.) M (S.E.) M (S.E.) Nonverbl behviour Eye gze (0.050) (0.044) (0.054) (0.051) 0.50 Affirmtive hed nodding (0.008) (0.007) (0.008) (0.008) 0.40 Smiling (0.007) (0.007) (0.008) (0.008) 0.25 Forwrd lening (0.012) (0.011) (0.013) (0.012) 0.60 Affective touch (0.018) (0.015) (0.018) (0.018) 0.10 Globl ffect rtings Anger/ irrittion 1.00 (0.027) 1.04 (0.024) 0.99 (0.029) 1.02 (0.027) 0.60 Nervousness 1.01 (0.108) 1.10 (0.102) 1.06 (0.118) 1.25 (0.114)* 0.50 Dominnce 2.52 (0.142) 2.50 (0.125) 2.24 (0.149) 2.43 (0.139) 0.40 Interest 4.41 (0.165) 4.89 (0.154)** 4.27 (0.179) 4.42 (0.173) 0.08 Wrmth 4.36 (0.187) 4.87 (0.176)*** 4.36 (0.204) 4.51 (0.197) 0.07 Ptronizing 1.42 (0.154) 1.17 (0.145)* 1.48 (0.168) 1.24 (0.162) 0.90 Involved ttitude 4.02 (0.167) 4.31 (0.156)* 4.09 (0.181) 4.18 (0.174) 0.30 Men durtion encounter 15.8 (1.7) 14.2 (1.5) 12.2 (1.8) 13.2 (1.7) 0.25 (min) Significnce level bsed on interction tests of men pre-test post-test differences in experimentl nd control group. Pre-test versus post-test: * P # 0.05; ** P # 0.01; *** P # revels tht trined nurses improved more in show- Finlly, it ws tested whether the ptients shre in ing interest nd wrmth thn the untrined nurses, encounters of trined nurses chnged more thn but only in the home for the elderly (Tble 6). All of ptients shre in encounters of untrined nurses. The the other nonverbl behviour vribles nd globl right column of Tbles 7 nd 8 shows tht none of ffect rtings of the trined nurses did not improve these differences rech sttisticl significnce, insignificntly more thn those of the untrined nurses. dicting tht ptients receiving cre from trined nurses, chnged in the sme wy s ptients receiv Ptients shre in the interction ing cre from the untrined nurses. In home cre, ptients who received cre from trined nurses showed less disgreement during the 5. Discussion interction (Tble 7). Moreover, they gve more informtion bout nursing nd helth topics nd their The im of this evlution study ws to explore lifestyle. Finlly, ptients of trined nurses more the effects of communiction trining, bsed on often cme up with ides of their own nd solutions Video Interction Anlysis. Findings within groups to their problems. These differences were not ppr- indicte tht communiction ptterns do indeed ent in the control group. chnge. This counts especilly for the nurses in In the home for the elderly no effects were found, home cre. We found tht nurse communiction fter with respect to ptients shre in the interction trining ws more fcilitting. Nurses showed less (Tble 8). Contrry to our expecttions, the speking disgreement, used more open-ended questions nd time of ptients in the control group incresed. gve more informtion. Furthermore, these nurses

10 100 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) Tble 7 Weighted men proportions nd stndrd errors for ptients verbl communiction composites t pre- nd post mesurement, in the home cre orgnistion Vribles Experimentl group Control group P Pre Post Pre Post n 5 44 n 5 43 n 5 31 n 5 35 encounters encounters encounters encounters M (S.E.) M (S.E.) M (S.E.) M (S.E.) Verbl composites Disgreement (0.003) (0.003)*** (0.004) (0.004)* 0.60 Questions (0.003) (0.003) (0.004) (0.004) 0.70 informtion (0.033) (0.034)*** (0.041) (0.037) 0.30 Counselling nd dvice (0.001) (0.001)*** (0.001) (0.001) 0.12 Speking time (min) 4.32 (0.266) 3.97 (0.270) 3.57 (0.334) 3.53 (0.295) 0.50 Significnce level bsed on interction tests of men pro-test post-test differences in experimentl nd control group. Pre-test versus post-test: * P # 0.05; ** P # 0.01; *** P # Tble 8 Weighted men proportions nd stndrd errors for ptients verbl communiction composites t pre- nd post mesurement, in the home for the elderly Vribles Experimentl group Control group P Pre Post Pre Post n 5 43 n 5 44 n 5 38 n 5 38 encounters encounters encounters encounters M (S.E.) M (S.E.) M (S.E.) M (S.E.) Verbl composites Disgreement (0.003) (0.003) (0.003) (0.003) 0.15 Questions (0.005) (0.004) (0.005) (0.005) 0.70 Informtion (0.044) (0.039) (0.047) (0.044) 0.70 Counselling nd dvice (0.000) (0.000) (0.000) (0.000) 0.90 Speking time (min) 4.26 (0.300) 4.38 (0.269) 3.67 (0.319) 4.47 (0.300)* 0.40 Significnce level bsed on interction tests of men pre-test post-test differences in experimentl nd control group. Pre-test versus post-test: * P # communiction ctegories, we see effects in the mount of counselling nd dvice. It is not completely cler how differences in both settings cn be clrified. As we concluded in n erlier study, the nurses in the two settings did not differ with respect to ttitudes towrds elderly peo- ple, therpeutic ttitude, job stisfction or personl chrcteristics [32,38]. A possible explntion might be the chrcteristics of the setting. In institutionl cre, dily ctivities re more tightly scheduled thn in home cre. Nurses nd ptients on the wrd hve to do with the wrd culture nd dily routine. In were rted s more interested nd involved, wrmer, nd less ptronizing. Although the trining is primrily directed t nurse communiction, the chnges in interction extended to the ptients s well. Ptients of trined nurses showed decrese in disgreement, they gve more informtion nd produced their own solutions more often. The effects in the home for the elderly were less convincing nd minly limited to the emotionl tone during the encounter, ssessed on the globl ffect scles. After the trining nurses showed more involved nd wrmer ttitude. As regrds verbl

11 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) home cre, ptients live independently, re visited by lso cynicism or rrognce [17,18]. To observe these their nurse nd wrd chrcteristics do not influence behviours in more vlid wy, one should hve nurse ptient interction. Perhps, this independence more thn one video cmer nd record from differis conducive to the implementtion of the communi- ent ngles. The use of such methods is not possible ction skills lerned. in nursing prctice, but is restricted to experimentl There were some other unexpected findings tht rrngements. need to be clrified. Firstly, we hypothesized tht Another point of concern is possible selection nurses would express fewer dominnt behviours. bis, s result of the fct tht nurses recruited the No significnt effects were found in this respect; ptients for the study themselves. This procedure of lthough, in the home cre setting, nurses did show ptient selection my hve resulted in bis of the decrese in ptronizing behviour. Trined nurses in effects, becuse nurses might hve selected, with the home for the elderly showed decrese in the whom they were getting on well together. However, type of communiction tht structures encounters. the methods were similr for experimentl nd The chrcteristics of this type of communiction control group, so both groups were dvntged ment tht we could interpret this effect positively. A eqully much. mjority of utternces in this cluster re orientting Aprt from questions of selection bis, there ws nd instructionl remrks like let s strt you cn limittion in the study concerning the qusi-exgo to the bthroom nd sking for understnding or perimentl design. The results showed tht the nurses clrifiction. Use of these utternces structures the in the experimentl group chnged significntly on interction from the nurses point of view. In tht severl scores. This ws especilly true for nurses in sense, decrese in this kind of communiction home cre. When looking t the control group, there might indicte decrese in dominnce. Similrly, were lso chnges in the desired direction, lthough the decrese in counselling nd dvice, which we mostly non-significnt. Chnges in communiction found in the experimentl groups in both settings ptterns in both conditions my not only be due to could be interpreted s n effect in the desired the intervention, but lso to prticipting in the direction. These kind of utternces do not lwys project. All prticipting nurses hd bsic nurse support ptients to find their own nswers, nd if trining nd my be expected to hve knowledge on ptients not specificlly sk for dvice they cn even effective communiction in nursing. The control be ptronizing nd dependency creting [10]. nurses were exposed twice to video mesurements Secondly, trined nurses in home cre showed together with the experimentl group, they however significnt decrese in smiling nd lening forwrd, hd no trining. The possibility of contmintion which could not be ttributed to different types of between groups, the effect of video-recording nd nursing cre provided, becuse the scores were knowing tht it hs something to do with communicontrolled for this. In sense, these results re ction could hve trgeted erlier input on communidisppointing becuse these behviours re consid- ction, leding to dpttions in behviour in both ered to be importnt in estblishing good reltion- conditions. When iming to drw conclusions on the ship with the ptient [16,17]. Smiling my be one of effect of the intervention per se, comprison should the most importnt chrcteristics of nurse who be mde between differences in the experimentl wishes to estblish good rpport with ptients group nd the control group. Doing this, we were [17,42], while lening forwrd is sign of ttention confronted with the problem tht observtions t the nd conveys wrmth nd friendliness [43]. encounter level were used to mesure effects of n This brings up the importnt issue of conceptul intervention t the nurse level. For ech nurse vlidity. Actully, nonverbl behviour is more number of three or four encounters ws videotped complex thn we suggested in this pper. Some in the pre-test nd the post-test phse of the study. nonverbl behviours re multi-interpretble. For The encounters were chrcterized by heterogeneity, instnce lening forwrd combined with eye gze mening tht t pre- nd post mesurement different direction cn both indicte pying ttention nd ptients were involved nd lso different types of dominnce [42]. Smiling cn convey friendliness but cre were concerned. In the multi level model we

12 102 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) corrected for interdependency on nurses level nd Spreeuwenberg, MSc, nd Jn J. Kerssens, PhD, types of encounters. Still there ws lot of vrition NIVEL Foundtion Utrecht, in the sttisticl nlysis for which correction ws not possible. These circum- of the study. stnces did not llow us to clculte differences between pre-test nd post-test scores in the experimentl nd control group, which is the trditionl method in design with repeted mesures (MAN- References OVA). To ddress this problem we tested men [1] Noln M, Grnt G, Noln J. Busy doing nothing: Activity differences between pre- nd post-test in the exnd interction levels mongst differing popultions of perimentl group ginst men differences in the elderly ptients. J Adv Nurs 1995;22: control group by mens of interction-tests. This [2] Slmon P. Interctions of nurses with elderly ptients: method filed to demonstrte ny significnt differ- reltionship to nurses ttitudes nd to forml ctivity periods. ence in chnge between the experimentl nd control J Adv Nurs 1993;18:14 9. [3] Armstrong-Esther CA, Sndilnds ML, Miller D. Attitudes group. Only some trends in the desired direction nd behviours of nurses towrds the elderly in n cute cre were found. Compred to the trditionl pproch setting. J Adv Nurs 1989;14: the interction tests seemed to be less powerful to [4] Armstrong-Esther CA, Browne KD, McAfee JG. Elderly detect significnt between-group differences. ptients: still clen nd sitting quietly. J Adv Nurs Subsequently, conclusions on the effects in the 1994;19: [5] Mcleod-Clrk J. Nurse ptient communiction: n nlysis experimentl group should be tken with cution. On of converstions from surgicl wrds. In: Wilson-Brnett J, the bsis of systemtic observtions of nurses verbl editor, Nursing reserch: ten studies in ptient cre. Chind nonverbl behviour, we my sy tht there were chester: Wiley, some interesting results which might be induced by [6] Wters KR. Getting dressed in the erly morning: styles of Video Interction Anlysis trining, especilly in the stff/ ptient interction on rehbilittion hospitl wrds for elderly people. J Adv Nurs 1994;19: home cre setting. Yet, due to limittions in reserch [7] de Wilde I, de Bot K. Tl vn verzorgenden tegen ouderen methods nd study design the evidence is not strong in een psycho-geritrisch verpleeghuis (Lnguge in nursing enough s proof. the elderly in psycho geritric nursing home). Tijdschr Although this rticle only provides informtion Gerontol Geritr 1989;20: bout chnges in communiction behviour, it ws [8] Bouchrd Ryn E, Hmilton JM, Kwong See. Ptronizing lso found tht the trinees ssessed the trining the old: How do younger nd older dults respond to bbytlk in the nursing home? Int J Aging Hum Dev course positively on most counts [28]. They consid- 1994;39: ered the eductionl method pproprite for lerning [9] Bouchrd Ryn E, Mclen M, Ornge JB. Inpproprite communiction skills nd evluted the trining ccommodtion to elders: inferences bout nonverbl correltes. method s meningful nd relevnt to dily nursing Int J Aging Hum Dev 1994;39: prctice. Summing up these findings, it my be [10] Hewison A. Nurses power in interctions with ptients. J Adv Nurs 1995;21: concluded tht trining bsed on Video Interction [11] Cns GJ. Lten prten: een onderzoek nr opvoedingson- Anlysis is suitble when trgeting chnge in the dersteuning op het consulttiebureu (Let s tlk: n invescommunictive behviour of nurses in the cre of the tigtion to prent support on the consulttion office). Utrecht: elderly. Effects of the trining method should be SWP, replicted in rndomized controlled design, using [12] Bensing JM, Kerssens JJ, vn der Psch M. Ptient-directed gze s tool for discovering nd hndling psychosocil lrger smple sizes. problems in generl prctice. J Nonverb Behv 1995;19: [13] Mehrbin A. Silent messges. Belmont, CA: Wdsworth, Acknowledgements [14] Roter DL, Hll JA. Doctors tlking to ptients/ ptients tlking with doctors: Improving communiction in medicl This reserch project is prtly finnced by the visits. Westport, CT: Auburn House, Dutch Ministry of Helth, Welfre & Sport, Deprt- [15] Strecher VJ. Improving physicin ptient interctions: ment for Policy on the Elderly. The uthors grteful- review. Ptient Couns Helth Educ 1983;4: ly cknowledge the ssistnce of Peter M.M. [16] Cris-Verhllen WMCM, Kerkstr A, Bensing JM. The role

13 W.M.C.M. Cris-Verhllen et l. / Ptient Eduction nd Counseling 39 (2000) of communiction in nursing cre for the elderly, review of [31] Roter D. The Roter method of interction process nlysis. the literture. J Adv Nurs 1997;25: Bltimore: Johns Hopkins University Press, [17] Heintzmn M, Lethers DG, Prrott RL, Cirns III AB. [32] Cris-Verhllen W.M.C.M. De Gruijter IM, Kerkstr A. De Nonverbl rpport-building behviors effect on perceptions kwliteit vn de communictie tussen verplegenden en of supervisor. Mng Commun Q 1993;7: oudere clienten (Qulity of communiction between nurses [18] Vrugt A. Betekenistoekenning n nonverble communictie nd elderly people). Utrecht: NIVEL, (Interprettion of nonverbl communiction). PhD dissert- [33] vn Dulmen AM, Verhk PFM, Bib HJG. Shifts in doctor tion. Amsterdm: University of Amsterdm, ptient communiction during series of outptient consult- [19] Burgoon K. Nonverbl signls. In: Knpp ML, Miller GR, tions in non-insulin-dependent dibetes mellitus. Ptient editors, Hndbook of interpersonl communiction, 2nd ed. Educ Couns 1997;30: Thousnd Oks, CA: Sge, [34] vn den Brink-Muinen A. Gender, helth nd helth cre in [20] de Wever MK. Nursing home ptients perception of nurses generl prctice: A comprison between women?s helth ffective touching. J Psychol 1977;96: cre nd regulr helth cre. Utrecht: NIVEL, [21] McCnn K, McKenn HP. An exmintion of touch between [35] de Gruyter I, Schirm M. Communictie met oudere ptienten nurses nd elderly ptients in continuing cre setting in (Communicting with elderly ptients). Mster thesis. Ut- Northern Irelnd. J Adv Nurs 1992;18: recht: University of Utrecht, [22] Moore JR, Gilbert DA. Elderly residents: perceptions of [36] Bensing JM. Doctor ptient communiction nd the qulity nurses comforting touch. J Gerontol Nurs 1995;21:6 13. of cre. Utrecht: NIVEL, [23] O Connor FW, Devine EC, Cook TD, Wenk VA, Curtin TR. [37] Inui TS, Crter WB, Kukull WA, High VH. Outcome-bsed Enhncing surgicl nurses ptient eduction: development doctor ptient interction nlysis. Med Cre 1982;20:535 nd evlution of n intervention. Ptient Educ Couns ;16:7 20. [38] Cris-Verhllen WMCM, Kerkstr A, Bensing JM. Nurse [24] Cox J, Mulhollnd H. An instrument for ssessment of elderly ptient communiction home cre nd institutionl videotpes of generl prctitioners performnce. Br Med J cre. Int J Nurs Stud 1998;35: ;306: [39] Henbest RJ, Fehrsen GS. Ptient-centredness: Is it pplicble [25] Wilkinson S. Fctors which influence how nurses communi- outside the West? Its mesurement nd effect on outcomes. cte with cncer ptients. J Adv Nurs 1991;16: Fm Prct 1992;9: [26] Prthin AR, Tylor F. Cn we insulte trinee nurses from [40] Hulsmn RL. Communiction skills of medicl specilists in exposure to bd prctice? A study of role ply in com- oncology: development nd evlution of computer smunicting bd news to ptients. J Adv Nurs 1993;18: sisted instruction progrm. Utrecht: NIVEL, [27] Heven CM, Mguire P. Trining hospice nurses to elicit [41] Rsbsh J, Woodhouse G. MLn commnd reference, version ptient concerns. J Adv Nurs 1996;23: , multilevel models project. London: Institute of Educ- [28] Etten GP. Project Deskundigheidsbevordering: verslg vn tion, University of London, een experiment (Project expertness promotion: report of n [42] Schbrcq MJ. Betrokkenheid en onderlinge gelijkheid in experiment). s-hertogenbosch: Kruiswerk de Bossche socile intercties (Involvement nd equlity in socil inter- Meierij, ctions). PhD disserttion. Amsterdm: University of Am- [29] Cris-Verhllen WMCM, Kerkstr A, Bensing JM. Nonver- sterdm, bl behviour in nurse elderly ptient communiction. J Adv [43] Reece M, Whitmn R. Expressive movements, wrmth nd Nurs 1999;29: verbl reinforcement. J Abnorm Soc Psychol 1962;64: [30] lec ProGAMMA. User mnul CAMERA: system for collecting nd correcting behviorl dt. Groningen: lec ProGAMMA, 1994.

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